MyMedications Action Plan (Tribal)

My Medications Action Plan
The MyMedications Action Plan is a tool your healthcare
provider (such as a community health aid, doctor,
pharmacist, nurse, nurse practitioner, or physician assistant)
can use to help you identify medications that may increase
your risk of a fall or car crash. Your healthcare provider can
help you make a plan to adjust your medications if needed.
How to Use the MyMedications Action Plan:
Bring this Action Plan and your MyMedications List with you to your medical visits and
review it with your healthcare provider. This will help you learn about every medication
you take, why you take it, and if it is still needed.

Steps for Your Healthcare Provider:
1.

Identify any prescription medications,
over-the-counter (OTC) medications,
vitamins, supplements, herbal products,
or traditional cultural medicines your
patient takes that may have side effects
that affect their risk of falling or their
ability to drive safely. This may include
medications or supplements that can
have interactions.

Remember to talk
with your healthcare
provider before
stopping or changing
medications you take.
Steps for You:

2. Discuss how each medication or
supplement identified can be adjusted
to reduce their risk of falls and
car crashes.

1.

3. Fill out the first two columns of the
table on the next page for each of the
medications or supplements identified
and create a plan with your patient.

2. Remember to update your
MyMedications List with any changes
that you and your healthcare provider
have made.

After your healthcare provider fills out
the first two columns of the table on the
next page, you can fill out the rest of
the table with your provider or after
your visit.

My Name: _________________ Date Prepared: ___________
Healthcare Provider Name: _____________________________
Healthcare Provider Phone: ____________________________
Follow-up Appointment Date and Time: __________________

To Be Filled Out by My Healthcare
Provider or Pharmacist
Medication We
Talked About

How We Will Change
This Medication

To Be Filled Out by Me
Why I Am Making
This Change

What I Did to Make
This Change

Date Change
Was Made

Questions to Ask My Healthcare Provider About My Medications
• What are the benefits or risks of stopping,
switching, or reducing the medication?

• What are the steps to take to adjust my
medication, if needed?

• What are the benefits or risks of continuing to
take the medication?

•

• What side effects may happen when stopping,
switching, or reducing the medication?

What other ways can I help manage the
condition for which I take the medication?
(For example, is there another medication or
behavior change I could try?)

For more information: bit.ly/CDC-MedicinesRisk
June 2022